2.0 Analysis 2.1 Introduction Because it was determined that the aircraft was airworthy prior to impact, and that the weather was suitable for visual flight at the time of the occurrence, it was necessary to concentrate on the human areas of flight planning in order to determine why the accident occurred. The following analysis, therefore, focuses primarily on fuel management and crew coordination. 2.2 Fuel Calculations During a discussion with the first officer on the last flight into Trout Lake, about 15 minutes out of Fort Simpson, the captain stated that the aircraft had 45 minutes of fuel remaining. After landing in Trout Lake with approximately 30 minutes of fuel remaining, the aircraft departed for Fort Simpson with less fuel than the minimum required as outlined in the Air Regulations and company requirements. The previous two flights to Fort Simpson had taken 35 minutes; however, the captain still felt that there was enough fuel remaining to complete the flight to Fort Simpson. Neither pilot was sufficiently conscious of the minimum fuel requirements outlined in the Company Operations Manual. There was no evidence that company management placed any pressure on company pilots to continue flights with less than the minimum fuel requirements. The self-dispatch policy used by the company placed full responsibility for all decisions, after the flight was assigned, with the pilot-in-command. The fuel dip-stick, which is used to cross-check the accuracy of the fuel gauges, could not be located during the last station stop fuel check. Although the accuracy of the fuel gauges may have been jeopardized without the dip-stick reading, a visual check of the fuel tanks through the eight-inch diameter filler cap would have revealed the approximate fuel quantity. Thus, the dip-stick would merely have confirmed the low fuel status as indicated on the fuel gauges. 2.3 Pilot Decision Making In the absence of any management pressure, mechanical malfunction, or any other identified source of external influence, it is apparent that the captain chose to attempt the flight with fuel below the minimum requirements. The company requirements and the aviation regulations require extra fuel for reserves and contingencies to provide for a margin of safety. It was the captain who decided the flight could be completed safely. His calculations must have been incorrect. The final decision to fly with low fuel was also made in the context of risk assessment attitudes influenced by remote flying operations which, at times, may result in higher levels of risk. However, it is clear that, in deciding on this course of action, the captain misjudged the fuel requirements necessary to safely complete this flight. 2.4 Crew Coordination In multi-crewed aircraft, team-work is essential for the detection of errors in various areas, such as fuel management. Effective cockpit communications are essential to good team-work. Neither the captain nor the first officer had received formal training from this company in CRM or PDM, although the captain had taken a CRM course with a previous employer. Following a discussion regarding the aircraft's fuel status at the previous station stop, the captain's fuel calculations and decision to conduct the accident flight were consequently accepted by the first officer. Although the calculations differed, the first officer, who had much less flying experience than the captain, did not sufficiently assert himself regarding the aircraft's low fuel state. 2.5 Shoulder Harnesses Both pilots received injuries to the head and upper body, likely because they were thrown forward against the instrument panel and controls on impact. The aircraft was not equipped with shoulder harnesses. If shoulder harnesses had been available and worn by the flight crew, the injuries might have been less severe, or prevented. 3.0 Conclusions 3.1 Findings The flight crew was certified, trained, and qualified for the flight in accordance with existing regulations. The aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures. The aircraft was airborne for 4 hours and 37 minutes without refuelling. The engines stopped on approach because of fuel exhaustion. There was no evidence found of any airframe failure or system malfunction prior to or during the flight. Damage to the propeller systems was consistent with a lack of power at the time of impact. The flight crew operated the aircraft with less than the required company minimum quantity of fuel as outlined in Section 1, page 33, of the Company Operations Manual. The flight crew operated the aircraft with less than the minimum required quantity of fuel as outlined in ANO, Series VII, No. 2, sections 26 and 27, and Air Regulation 544. Neither of the flight crew members had received formal CRM or PDM training from the company. Shoulder harnesses, although not required by regulation, were not installed in the aircraft, and both crew members received injuries to the head and upper body. 3.2 Causes The flight was commenced with a fuel quantity below the minimum requirements, resulting in loss of engine power because of fuel exhaustion. Contributing to the occurrence was the lack of flight crew coordination. The Board has no aviation safety recommendations to issue at this time.4.0 Safety Action The Board has no aviation safety recommendations to issue at this time.